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Reprinted from ANNALS OF INTERNAL MEDICINE Vol. 103; No.4 October 1985 Reprinted in USA
Consultation and Referral Between Physicians in New Medical
Practice Environments
WILLIAM A. SCHAFFER, M.D.; and FRANK C. HOLLOMAN,Jr., J.D.; Memphis, Tennessee
The traditional exchange of medical expertise between physicians for patient benefit has been accomplished by referral.
Physicians have traditionally decided when and to whom to refer patients. Health care "systems" now dominate medical
practice, and their formats can alter spontaneous collegial interaction in referral. Institutional programs now pursue patient
referrals as part of a marketing strategy to attract new patients who then become attached to the institution, rather than
to a physician. Referral behavior can affect a physician's personal income in prepaid insurance programs where referrals are
discouraged. The referring physician may bear legal liability for actions of the consultant. New practice arrangements and
affiliations may place physicians in financial conflict-of-interest situations, challenge ethical commitments, and add new
moral responsibility.
PHYSICIANS do not practice in isolation (1). Assistance is frequently needed from colleagues to manage patients, and those
colleagues in turn require assistance to manage their patients. This exchange of expertise may be through consultation, where
advice or special studies are requested while responsibility for a patient remains with the initial physician, or through
referral, where some or all responsibility for the patient's care is transferred from one physician to another (2).
These are two distinct modes of exchanging expertise, differing primarily in duration and permanence, for in some sense a
referral may be viewed as a longer-term consultation. Both methods, however, share the common purpose of pooling medical knowledge
for the patient's benefit. The terms referral and consultation will be considered interchangeably as referral hereafter.
The Referral Process
The frequency of referral differs between physicians by as much as 15- to 25-fold in clinical studies (3). In clinical
simulation studies where several physicians reviewed identical cases and made dispositions, referral rates differed by 8-
to 19-fold(4). Although it appears that individual physicians each have a unique "referral threshold"(5), the overall
rate of patient referrals by primary-care practitioners (6) and internists (8) is 3% and 4% of clinic visits, respectively.
Some important variables such as physician age and specialty (4,6), and patient age and sex (6) clearly affect referral rates.
One key factor affecting referral rates is the form of reimbursement for the physician. Use of consultative services
was compared among three separate groups of physicians practicing in the same hospital who were paid for their services in
different ways (8) . The physician group for a prepaid insurance plan used consultative
600 Annals of Internal Medicine. l985;103:600-605.
services the least. Unaffiliated, fee-for-service physicians ordered an intermediate number of consultations. The members
of a large multi-specialty fee-for-service group practice made the most referrals of all three groups. The members of this
group derived shared income from internal consulting fees generated within the group. With financial incentives
for use of consultation, more referrals were made (8).
Various models and adapted decision-making theories have been applied to the referral decision, in attempts to understand
physician motivations and interests (9). This type of approach is helpful, but it is highly subjective and not directly applicable
to clinical situations. The most pertinent information has come from clinical studies and practitioner interviews, which show
that the referral decision has two parts: whether to refer, and to whom to refer. One large study (3) of the referrals of
general practitioners found that the decision to refer was made on the basis of the practitioner's personal clinical knowledge
and skills, clinical judgment, and the prevailing local standards of medical practice. Bosk ( 10) observed that, in clinical
reality all that is required to generate a referral is uncertainty about any aspect of a case. Request or demand by the patient
for another medical opinion will usually cause a referral, but because this request is usually interpreted by the treating
physician as a failure on his or her part, it is probably under-reported in most studies.
A study (3) of the second half of the referral decision, selection of a specific consultant (done in Britain, where
physician income is not substantially affected by referral activity), found that the choice of a specific consultant was based
on the referring physician' s knowledge of his or her place in the local health care environment. Based on this knowledge,
the physician made a judgment of the various types of specialties that might be used to treat a condition, with an assessment
of their accessibility and availability. Then a judgment of the specialists them selves was made based on an opinion of their
interactional style and professionalism. This judgment was balanced against the perception of the patient's values. Because
the probability of a "successful" encounter between a patient and the chosen consultant is of utmost importance,
the second half of the referral decision, choosing a particular consultant, can be the most difficult.
Attempts have also been made to explain consultant selection in fee-for-service settings. A ranked ordering of factors
important in selecting a consultant was elicited from general practitioners and general surgeons reimbursed on a fee-for-service
basis (2). Of foremost concern to these clinicians were technical issues related to patient
1985 American College of Physicians
care, and the quality of patient management. Matters of concern to the patient such as convenience and preference were
ranked as less important. Factors related to the physician, such as loss of income and concern over recip- rocal referrals
were ranked as least important in the selection of a consultant. This ranking was derived solely from interview responses,
and may not reflect actual clin- ical practices.
Whatever their subjective ranking, in fee-for-service settings there clearly were factors that were not medical, technical,
or related to the patient, but which played an integral part in the referral decision. Six of the twelve physician-related
components identified in the interviews were entirely unrelated to patient care or outcome, and represented internal incentives
for the referring physician (2). Concern for personal income, status in the local pro- fessional community, and generation
of reciprocal refer- rals affect consultant selection. One cannot estimate the weight of these concerns separately, but reciprocal
refer- ral is commonly known to carry substantial weight among practicing physicians.
All physicians receiving referrals pay attention to patient origin. Patients referred by other physicians provide
a major source of income, contributing 8% to 15% of outpatient visits, and over 30% of inpatient visits (7, 11). Sizable numbers
of these patients also become long-term patients for specialists ( 12, 13). Detailed information on the origin of these patients
is commonly obtained and maintained by widely available practice-management computer software programs ( I4) or in traditional
office files ( 15). Reciprocity for referrals can be based on this information, and it might be expected that perquisites
extended by consultants to referring physicians, such as invitations to sporting events, entertainment, and ski lodges may
be linked to this information.
Referrals are also used by new physicians to develop contacts and enter local practice networks. A targeted and judicious
assignment of referrals can assist advance- ment within the ranks of institutions or professional soci- eties. No estimate
of the percentage of referrals that are of marginal medical necessity, but are politically advanta- geous, is available.
The medical and political use of referrals is widely regarded as an astute business technique. So long as not carried to
extreme, it is unlikely that these opportunistic practices unfavorably affect patients. Patient care may actually be improved
by the additional attention, observation, and cumulative physician time. These types of referral techniques do, however, generate
additional charges to patients (16-18).
Health care is rapidly being reorganized into larger operating systems organized along lines of national and regional
ownership, and by reimbursement programs. Physician practice, meanwhile, is increasingly dominated by large physician groups,
closed associations, prepaid plans, and payer-controlled practice formats (19). The systematization of medical practice can
constrain use of consultative assistance by physicians and has altered the ability of clinicians to define their practice
boundaries.
In many prepaid systems administrative clearance is required before a consultation can be requested. Admin-
istrative "gatekeepers" may arbitrarily set thresholds or quotas for referrals and allow only a limited number
of referrals based upon capitation, diagnostic classification, or previous consultations used for a specific patient (20).
Reimbursement restrictions or organizational barriers can prohibit use of accustomed consultants and require practitioners
to use unfamiliar specialists. Flexibility in the degree of consultant involvement in case management can also be sharply
curtailed by policy or shortages.
Many health care systems are aggressively assembling vertically integrated corporate networks comprised of satellite
hospitals, ambulatory clinics, and alliances be tween institutions designed to "feed" new patients into institutional
programs and garner their market share. Patients who are acquired by a system and "fed" into insti- tutional
programs are not attached to individual physi- cians. These patients "belong" to the system and must be distributed
among the medical staff by some means. In some cases these referrals are distributed as incentives and rewards by the institution's
administration for physicians' cooperation with them in other matters ( 21). Institutional referral-assignment programs
can be effective. In one study of patients who entered an institution unattached to any physician, voluntary compliance by
the patients in keeping their referral assignments ran as high as 70%; many of these patients subsequently became excellent
users of the physicians' offices to which they had been initially referred (22).
In this new environment for medical practice, four areas of concern for physicians emerge. First, physicians independently
making referral decisions must make sound patient-based decisions in radically different practice surroundings. Second, physicians
in these systems must preserve the professional sovereignty essential in making referral decisions that protect patient welfare
and meet their professional needs. Third, all physicians must be aware of the potential legal implications of their refer-
ral decisions. Fourth, all practicing physicians must review commitment to ethical traditions and evaluate new practice
formats for potential conflicts of interest.
The decision to seek medical consultation or to refer a patient has traditionally been made independently by the physician
treating a patient. Once the decision was made, a specialist was selected from a close circle of colleagues with whom the
physician felt comfortable and was a respected peer. The physician and specialist shared similar backgrounds, interests,
and perhaps education or post doctoral training.
A physician sought medical advice when necessary and for whatever reason justified that action. Assistance may have
been sought because of unforeseen complications, or because new laboratory findings took the case outside the physician's
usual realm of practice. By so doing, each physician set and maintained boundaries on the extent of his or her practice and
defined clearly a secure range of competence. Individual medical practice was composed of cases with which a physician felt
qualified, comfortable, and interested.
These boundaries of practice were dynamic; expanding as the physician acquired new training or interests, per-
Schaffer and Holloman; Physicians and Patient Referral 601
haps stimulated by information obtained from a consultation; or shrinking because cases were excluded that were seen
infrequently or in which there was a lack of interest. d Medical advice was sought from whomever the physician wanted.
In urban settings, advice was exchanged between peers within the same institution; and in rural settings, advice was obtained
by sending the patient to a specialist in a nearby urban center. In both settings, the physician typically drew from a cadre
of specialists personally known to him or her, although a new consultant could be selected on the basis of word-of-mouth recommendation,
a joint consultation experience, or favorable encounter in a medical staff conference. Former consultants may have been replaced
because of poor service, office relocation, or for personal reasons. From this arrangement the patient benefited by receiving
state-of-the art care for problems outside of the own physician's expertise from consultants respected and known
by the physician.
Ethical Considerations in Referral
The practice of medicine has been defined as a "unique and intrinsically moral profession" that stands
alone among the professions because its primary activity, healing, "is both in principle and in fact, distinct from the
activity of gaining remuneration for healing ( 23)." Medicine is also unique in prohibiting the payment of fees for referral
of patients. These split fees are an important revenue source for attorneys and other professionals, but are outlawed
to physicians on both ethical (24-26) and statutory grounds (27).
The disparate treatment of physicians and lawyers regarding the dividing of fees for common clients (patients) lies
in the method of recovery of fees by the two professions. Physicians historically charge certain fees for certain services
and therefore can bill common patients separately for services rendered by different physicians (25). A fee-splitting referral
system for physicians is unnecessary because of the way in which medical fees are generated and billed. Fee splitting is
undesirable for many reasons, but primarily for its potential to distort and subvert relationships between physicians and
patients, and between physicians themselves.
Lawyers, on the other hand, take many of their cases on a contingent-fee basis, sharing the recovery with the client
on a percentage basis. When there is more than one lawyer representing a client, the lawyers must necessarily share the common
fee with each other on a percentage basis. The referral system for lawyers, with the splitting of fees allowed, tends to enhance
the quality of legal services to the client. Fee splitting encourages a referring lawyer to bring in an expert, win the
case, and still receive a fee, as opposed to handling a case outside of his area of competence and chance losing the case
and thus the fee.
There are frequently rumors that some medical specialists may actually pay referring physicians in exchange for patients
in highly competitive or overcrowded medical communities. No factual reports of such activity could be found in the literature.
There is, however, a report of physicians paying a company to gather and refer patients. The company was paid according to
the volume of new patients it generated, and the patients were apparently not informed of the arrangement (28).
The American College of Physicians ethics manual
(24) cites only two ethically acceptable motivations for patient referral: when assistance is required in the care of
the patient, and when consultation is requested by the patient or his or her agent. Furthermore, the manual mandates that
"the physician must avoid any personal commercial conflict of interest that might compromise his loyalty and treatment
of the patient. Collusion with
... colleagues for personal financial gain is morally reprehensible" (24). Reactivated concern over financial conflict
of interest now includes physician equity ownership in hospitals where his patients are treated, satellite clinics that refer
patients to him, ambulatory surgery centers where he does the surgery, and nursing homes used to board his patients. As more
physicians become in-house employees of non-medical corporations, management responsibilities may also generate new interest
conflicts (29).
Another form of potential conflict has arisen in prepaid health insurance plans where a physician's remuneration may
be affected by the use of consultants. There may be pressure to select the cheapest consultant rather than the best (30-32).
Other insurance plans may bill the physician directly for consultant's fees, to be paid from a fund the physician administers
and shares in the year-end residual balance (18,32). These arrangements place physicians in awkward positions, bearing moral
responsibility for consultant's actions(33), yet gaining financially from the use of lower-priced consultants. Physicians
must be vigilant in avoiding any potentially compromising monetary involvements , for "in the final analysis no external
factors should interfere with the dedication of the physician to provide optimal care for his patient" (34).
Patient Referral as a Marketing Strategy
Medical advertising was first allowed in 1980 (35), and physicians of all specialties responded by advertising their
services directly to the public with accelerating intensity (36). Increased spending by medical advertisers coupled with
unexpected levels of tolerance by the profession have broadened the scope of medical advertising to include Madison Avenue
techniques unthinkable in the medical world 6 years ago (37). These radical developments have prompted the Federal Trade
Commission to consider reintervention in the medical marketplace. The agency has invited comment on its potential role and
activity in implementing standards for deception and truthfulness in medical advertising (38).
Advertising by physicians in many instances now rivals
the marketing sophistication of large health care institutions. Several levels of presentation and communication 39),
including public relations techniques, are used to "position" (40) physician services in a particular niche in
the marketplace by creating an overall image that appeals to the public. Larger physician groups and institutions can advertise
basic health services directly to con-
602 October 1985 8226; Annals of Internal Medicine; Volume 103 8226; Number 4
sumers, but it has not yet proved effective or efficient to market tertiary or specialty physician services directly to
patients. These complex services are more efficiently marketed to physicians who treat consumers. Once the targeted physicians'
commitment has been obtained through a marketing program, the patients requiring tertiary and specialty services will be referred
to them.
Some of these marketing techniques may not require large sums of money to be effective. For example, a number of unaffiliated
specialty physicians practicing in the same city established a company to market their services to primary physicians in outlying
areas. This cooperatively owned company attempts to cultivate patient referrals by currying favor with established and potential
referring physicians (41). The company's marketing program includes a monthly newsletter; free comprehensive physical examinations
for referring physicians; and expensive dining, entertainment, and sporting junkets for these physicians. Additional benefit
programs for referring participants, such as practice management consulting, bulk purchasing discounts, and investment
services may also be provided by this group.
More customary and restrained examples of the marketing of referrals may include educational services, and professional
courtesy for the treatment of the families of referring physicians. Excellent levels of patient care, accessibility, and
dignified treatment of the referring physician are essential components as well.
Programs to market physician referral services also exist in academic medical centers. Regional telephone referral
programs with toll-free numbers using university faculty as consultants (42) began to spread early in the 1980s. Dozens
of programs now exist allowing a physician anywhere to call for an immediate and personal consultation or to make a referral
directly to a faculty member (43). University hospital in-house consultative services have been revamped to provide easier
access for the community physician and also for other academic specialty services. Results from one center where a general
medicine consultative service was restructured showed a "dramatic" increase in both the volume and the sources of
referrals ( 44).
The most expensive and permanent technique to secure patient referrals is simply to purchase the source (45), as large
regional hospitals have done by acquiring smaller neighboring hospitals. The smaller units serve as satellites, "feeding"
patients to the parent institution. Free standing ambulatory clinics have recently emerged as sources of patients, and institutions
have begun to build or acquire clinics in city-wide sites to extend the referral base for patients (46). "Physician
locator" programs have been mounted with heavy media support in many cities. Run by the institutions, these programs
advertise their medical staff to the public and encourage patients to call the hospital for referral to a member of their
staff. Another method of assuring permanent patient sources is a joint venture between a physician group and an institution.
One major example of such a venture is the recent arrangement between a large regional medical group located at several
sites and a national investor-owned hospital corporation in which a substantial investment made in the medical group permanently
secured its patient base for the corporation's hospital (47). There are numerous examples of similar joint ventures on a smaller
scale (48).
Closer scrutiny by regulatory and licensing agencies for potential conflicts of interest may be applied to non- traditional
marketing programs directed to physicians, and to business arrangements that require treating physicians to use only one
institution or panel of consultants. More formidable obstacles to the spread of these programs may arise from consumers. Resentment
and resistance may develop as consumers legitimately question the motivation and intent of physicians referring them to consultants
under these circumstances. A loss of consumer confidence will certainly develop if it is revealed that a physician's income
is affected by his referral decisions.
Additionally, there is growing pressure for health care institutions to disclose their internal quality-of-care statistics
(49). Information on the outcome of specific procedures, including morbidity and mortality rates, may soon be available
for review and comparison by consumers. In this environment, even the most expensive marketing program could not overcome
negative public opinion and poor quality-of-care ratings. The enduring core of any successful long-term medical marketing
strategy will be the excellence of its clinical programs coupled with qualified, accessible, personable , and compassionate
consultants.
Making Referrals
It must be remembered that in the patient's mind the referring physician always bears the moral responsibility for the
actions of the consultant. In some cases the physician may also bear the legal responsibility. Malpractice suits against
physicians who have referred patients to an other physician where the patient was damaged in some way is not a new concept.
The basis of the charge against the referring physician is that he either assisted the consultant in damaging the patient,
or should have known of the consultant's incompetence to treat the patient properly (50). Various legal theories have been
raised in the courts attempting to find the referring physician liable to the damaged patient. Depending on the facts of the
case, the relationship of employer-employee (51), principal and agent (51), respondeat superior (51), master and servant
(52), and partnership or joint-venture (52) have been alleged. The courts have mostly failed to find the requisite relationship
to exist, by whatever theory, unless the physicians were found to be acting in concert or for a common purpose.
It is clear, however, that certain types of medical practice arrangements can increase the liability exposure of the
referring physician for the damaging acts of his consultants. If the consultant is employed in any manner by the referring
physician, liability for negligent acts of the consultant is readily extended to the referrer (52,53). When referring and
consulting physicians work closely to manage a patient jointly and the care is later adjudged to have been negligent, both
physicians can be held liable
Schaffer and Holloman Physicians and Patient Referral 603
(54). The type and limits of a consultant's medical malpractice insurance coverage may indirectly affect exposure of
the referring physician to litigation over treatment rendered by the consultant. If a consultant has inadequate insurance
coverage, the litigants may focus on an adequately insured referring physician in attempts to gain a better monetary settlement
(55).
New applications of proximate cause may be found through attempts to include referring physicians in suits brought against
their consultants, especially when there was not a strong professional relationship between the two physicians. A patient
damaged by a consultant may contend that the referring physician shares the blame for the damage, because if the patient had
not been referred the damage would not have occurred. The referring physician would then be required to disclose the basis
for selecting that consultant. Under these circumstances, any nonmedical considerations or incentives extended to the physician
by the consultant would have become relevant and subject to disclosure.
If a physician refers patients to a consultant known to be inadequate or unsatisfactory, the physician may bear liability
for any bad result because of negligence in recommending that consultant (5O).
Consent must be obtained from the patient and record ed before a referral is made and not only for ethical reasons.
In at least one case, the referring physician was not held liable for the consultant's negligence because the patient had
consented to the referral at the time it was made (51). Patients should not be pressured or coerced to use an institution
for care simply because of internal protocols or proprietary interests. If a patient does not consent to an internal referral
program, he or she must not be abandoned, and every effort and consideration must be extended to assist that patient in receiving
care from a chosen source.
Once referral is made, the referring physician must make a clearcut clinical decision on the level of involvement and
interaction with the consultant, and the consultant's treatment of the patient. Involvement should be either complete and
closely coordinated, or restricted and peripheral to the consultant. In many respects, the less involved the referring physician,
the less liable he or she will be for negligence and error of the consultant.
It has been difficult to assign liability to referring physicians who were ignorant of wrongdoing by the consultant
(56) or who allowed the consultant to act independently (51). When the consultant does commit malpractice, the
referring physician has not been held liable if it was shown that a clear division of responsibility with the consultant
existed (57).
Referring physicians who remain involved with consultant care as a part of total patient management must continually
monitor the performance of their consultants, relying not only on written reports, but also patient feed back and their own
subjective impressions. An appraisal of consultants' credentials and background should be made before referring. When newer
technical procedures are contemplated, the referring physician should be familiar with the consultant's training, experience,
and
frequency of performance of these techniques before advising a patient. A consultant excelling in standard treatments
may not be adequately trained or experienced in state-of-the-art procedures.
In the event that the referring physician becomes aware of mismanagement, negligence, error, or incompetence by the
consultant, prompt clinical intervention must be initiated by the referring physician. Referring physicians who observe
and knowingly participate in negligent care by consultants (56, 58) or observe negligence and let it go without objection
(59) share responsibility for that negligence. Either correction or replacement of the consultant must be made immediately.
The issues must also be addressed in the medical record, and with the patient or his agent (60).
Consultants receiving a referred patient share common ethical and legal responsibilities. There must be assurances
that the patient willingly accepts the consultative services, and the extent of those services must be under stood by the
patient, referring physician, and consultant. It must be clear whether an opinion, a specific procedure or treatment, joint
management of the case, or full assumption of responsibility is desired, and whether it is temporary or permanent.
The consultant can assume full responsibility only at the spontaneous and uncoerced request of the patient, or at the
request of the referring physician (24, 26).
Conclusion
A review of the changing medical practice environment has shown that the ways in which physicians handle patient referrals
can be different from traditional ways. Collegial interaction is being replaced in some sectors by systematized formats
and limited-choice protocols. New financial opportunities, and medical and political influences affecting referral behavior
are being presented to practitioners. Some of these factors have the potential of interfering with patient welfare and pose
situations that may push practicing physicians into ethical and financial conflicts of interest.
Physicians must closely examine their own commitments to professional traditions before making decisions on how they
will handle patient referrals in nontraditional situations. New practice arrangements must be closely examined for potential
interest conflicts and for unacceptable constraints upon professional behavior. New health care organizations will generate
large numbers of patients attached to these institutions rather than to physicians. In caring for these patients, a physician
must "avoid any business arrangement that might, because of personal gain, influence his decisions in patient care"
(33).
ACKNOWLEDGMENTS: The authors thank J. Pervis Milnor Jr. , M.D., Robert I. Sandifur, M.D., John T. Vookles, M.D.
, and Eric H. Cornell for editorial assistance; and Donna L. Davis, B.S., for library assistance.
Requests for reprints should be addressed to William A. Schalfer, M.D.; 500 Main Street; Louisville, KY 40201-1438.
604 October 1985 Annals of Internal Medicine;
Volume 103; Number 4
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